Schizophrenia and other psychotic disorders have taken some time to reach the mainstream public health arena despite the prevalence, burden and cost of these conditions (1). A key reason for this is the stubborn nature of attitudes about psychosis.
The stereotype of a chronically psychotic institutionalized individual has its origins early in this century with Kraeplin's (the first researcher of what was later to become called schizophrenia - 1919) description and diagnosis of dementia praecox. In spite of new knowledge within psychiatry this impression has largely remained. Pessimism has also been rife amongst many mental health workers in the past, who have felt rather helpless in their inability to affect positive outcomes.
Integral to Kraeplin's model was the concept of deterioration, which he suggested took place within the first few years after onset of the disorder. Several challenges to this model have resulted from an increase in the research associated with first episode psychosis, and current knowledge suggests that intervening during these early years can have a significant impact on outcome (2). The period of time following onset has been called the 'critical period' (3), and is the crucial time to instigate optimal, integrated big-psycho-social interventions.
Research also suggests that a significant time period often separates the onset of psychotic symptoms and the initiation of appropriate treatment . Delays in treatment can have serious consequences for patients and their families. A growing body of evidence suggests that delays in the treatment of a psychosis can have serious effects on medium to long-term outcome (4). The duration of untreated psychosis has been associated with slower and less complete recovery, increased risk of relapse, and substantial treatment resistance (5,6). Given what is known about the 'critical period' and the risks of delayed treatment, early intervention can be seen as crucial for positive outcomes.
Early deterioration can be understood by considering secondary effects of the disease. The consequences of psychosis can have extremely serious effects on the individual and their family. These consequences may be more important in the so-called deteriorative process than the illness itself. Given that a first psychotic episode is likely to occur in adolescence and early adulthood, the disruptions caused by unrecognized and untreated symptoms can alienate the young person from their family and friends and disrupt their education and vocational functioning. This disruption to social networks, educational and vocational development and to personality formation can create major difficulties for the young person trying to establish identity and direction in life. For families who often do not understand exactly what is occurring, a great deal of distress results. Family conflict which exacerbates stress at home in turn impacts negatively on the individual experiencing psychosis. Delayed treatment is more likely to be associated with police intervention and compulsory admission to psychiatric hospitals established to deal with older chronically ill individuals. These aspects of treatment are obviously traumatic for the individual and their families and post traumatic stress disorder may be an outcome of the experiences. Other types of secondary effects include, social anxiety, depression, substance abuse and homelessness (7).
Despite the obvious need to intervene early, there are often lengthy delays between the onset of psychosis and effective treatment. Studies have found the mean length of untreated psychosis to be one year, with the mean length of total illness (including the prodrome - ed. note - Prodrome is a medical term for a symptom which indicates the impending outbreak of a disease) to be 3 years (4). There are a number of reasons for these delays in effective treatment.
Firstly, there are delays related to the inability of most individuals, their family and friends to recognize the signs and symptoms of psychosis. This is also the case, unfortunately, with many general practitioners and other primary care professionals.
Secondly, even if the illness is recognized, there is often a reluctance to seek help due as a result of the fear and stigma often associated with mental illness, and a lack of knowledge about where to obtain useful resources.
Thirdly, some services are inaccessible or non responsive.
Finally, the groups at risk of extended delays in treatment for a psychotic episode include homeless people, those with drug and alcohol problems and people with personality disorder and intellectual disability.
In summary, the consequences of psychosis cause much of the early deterioration that is seen in these disorders. Given this, delays in case identification, for the reasons discussed above, can be seen to represent a major public health problem (2,8).
Secondary morbidity can be minimized by early and vigorous treatment in the early phase of psychosis. Reducing treatment delay has is associated with better outcome, less disability and reduced financial costs over the long-term.
A preventative approach is needed to meet these goals. Secondary and tertiary preventative strategies enable a focus in the intensive treatment of first episode psychosis to promote recovery and repair disrupted networks.
Recent research has produced a range of clinical data which suggests that big-psycho-social treatments can make a difference to the long-term course and outcome of psychosis by reducing morbidity and disability (2,9,10).
1. Andrew's A, Hall W,, Goldstein G,, Lapsley H, Bartels R, Silove D. The economic costs of schizophrenia. Implications for public policy. Archives of General Psychiatry 1985; 8:245-253,.
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2. McGlashan TH, Johannessen JO. Early detection and intervention with schizophrenia: rationale. Schizophrenia Bulletin 1996; 22:201 -222.
3. Birchwood M, Smith J, Macmillan F, Hogg B, Prasad R, Harvey C, et al. Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers, a preliminary investigation. Psychological Medicine 1989; 19:649~56.
4. Loebl, A.D., Lieberman, J.A.., Alvir, J.M.J., Mayenhorf. D.l., Geisler, S.H. and Szymanski, S.R. (1992). Duration of psychosis and outcome in first episode schizophrenia. Am J.Psychiatry 149,1183~1188.
5. Johnstone, E.c.; Crow, Tj.; Johnson, A.L. and Macmillan, J.F. (1986) The Northwick Park study of first episode schizophrenia: I. Presentation of the illness and problems relating to admission. Br. J. Psychiatry 148.115~120.
6. Wyan, R.J. (1991) Neuroleptics and the natural course of schizophrenia. Schizophrenia Bull., 17, 325~351.
7. McGorry, RD. and Singh, B.S. (1995). Schizophrenia: risk and possibility of prevention. In B. Raphael and G.D. Burrows (Eds.) Handbook of studies on preventive psychiatry, Amsterdam: Elsevier.
8. Moscarelli M. Health and economic evaluation in schizophrenia: implications for health policies. Acta Psychiatrica Scandinavica 1994; 89 (suppl 382):8493.
9. McGorry PD, Edwards J, Mihalopoulos C, Harrigan SM, Jackson HJ. EPPIC: An evolving system of early detection and optimal management. Schizophrenia Bulletin 1996; 22:305~326.
10. Falloon, l.R., Kydd, R.R., Coverdale, J.H. and Laidlaw, T.M. (1996) Early Detection and intervention for initial episodes of schizophrenia. Schizophrenia Bulletin, 22 2), 271~282.